Culture appears to influence people's perceptions of narcotic pain relief
after surgery, say researchers who have surveyed fracture patients in Northern
California and in Vietnam.

US patients with fractures of the femoral shaft were much less satisfied
with the narcotic pain relief that their doctors provided, even at doses
more than 30 times greater than those received by a matched group of Vietnamese
patients, said Dr. Eugene Carragee, associate professor of functional restoration
(orthopedic surgery) at Stanford University School of Medicine.

"Many studies have demonstrated that pain can be subjective and
influenced by experience, but we were impressed at how large a role culture
appears to play in actually managing patients," said Carragee.

"This information is extremely useful because either too much or
too little painkiller can cause side effects and complications, and the
rough guidelines we employ aren't always particularly useful. We need further
research to determine better pain management standards," he said.
Carragee presented the new findings in February at the annual meeting of
the American Academy of Orthopedic Surgeons in San Francisco.

Femoral fractures are a particularly painful form of injury, and the
surgery to correct them is also associated with serious discomfort. The
procedure involves placing a rod into the bone to stabilize the fracture
and promote healing.

Study Results

All patients in the study received morphine or opioid analgesics to
relieve their pain. To assess pain relief, independent examiners, not the
patients' caregivers, conducted standardized interviews with each patient
between 12 and 16 days after surgery. Pain relief during surgery and in
the recovery room was not evaluated.

On average, the 25 Vietnamese patients in the study, at two hospitals
in Hanoi and one hospital in Ho Chi Minh City, received daily doses equivalent
to 0.9 mg/kg of morphine. Doses for the 25 US patients, at Stanford University
Hospital and Santa Clara Valley Medical Center in San Jose, averaged more
than 30 times higher, at 30.2 mg/kg/d. On average, the Vietnamese patients
weighed significantly less than the Americans, and dosage comparisons were
adjusted to account for this.

Despite the large difference in weight-adjusted dosage, only 8% of the
Vietnamese group, compared with 80% of the US group, said they felt their
pain control had been inadequate, Carragee said.

Possible Explanations for Differing Perceptions

Although the study did not attempt to identify the reasons for this,
Carragee does offer some speculation. "A strong history of privation
due to war, and a pervasive Buddhist tradition, whose first tenet is 'All
life is suffering,' may have colored the expectation of the Vietnamese
patients," said Carragee, who has worked as a physician on several
projects in Southeast Asia in recent years. In addition, "Vietnamese
people traditionally have great confidence in their doctors, and this faith
could explain a feeling of well-being, hence lack of pain, that came from
believing they were following the proper path," he said.

A surprising number of the US patients "believed there was some
factor or agent at work making their situation worse, be that a problem
with the bed or a suspected problem with the surgery," Carragee noted.

Preconceptions about how much a broken thighbone would hurt also varied
dramatically between the two groups, he said. Only 4% of the US group,
compared with 76% of the Vietnamese group, said the pain was about as strong
as they would have expected for such an injury. Almost all of the Americans
said that the pain was much worse than expected.

Carragee's colleagues on the pain study included Dr. David Burton, clinical
professor of functional restoration (orthopedic surgery) at Stanford and
head of orthopedic surgery at Santa Clara Valley Medical Center; Thao P.
Truong, a predental student at the University of California, Santa Cruz;
and Stanford medical student Daniel Vttum.

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